Chapter 10 TACTICAL FIELD SKILLS for the MILITARY PHYSICIAN

Tactical Field Skills for the Military Physician Chapter 10 TACTICAL FIELD SKILLS FOR THE MILITARY PHYSICIAN SEAN MULVANEY, MD,* and TONY S. KIM, MD† INTRODUCTION THE PROBLEM AND NEED FOR TRAINING SHOOT Weapons Training Combatives MOVE Principles of Navigation Driving Military Vehicles Convoy Operations Personal Equipment and Moving COMMUNICATE ADDITIONAL OPERATIONAL MEDICAL TRAINING Flight Medicine Dive Medicine Airborne Survival, Evasion, Resistance, Escape OTHER CONSIDERATIONS Military Bearing Medical Evacuation and Mass Casualty Planning and Training Preventive Medicine Operational and Intelligence Briefings Time Management SUMMARY *Colonel (Retired), Medical Corps, US Army; Associate Professor, Department of Military & Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland †Colonel, Medical Corps, US Air Force; Assistant Professor, Department of Military & Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland 153 Fundamentals of Military Medicine INTRODUCTION There are two compelling reasons for military phy- skills must be performed, and becoming proficient in sicians to learn and hone the basics of military combat them takes time, in some cases years. Although these skills. The first is that the physician must never be a skills may never be used in combat, they are worth liability for the supported unit. The second is that by learning and will increase the physician’s ability to fundamentally understanding the demands of the both care for and relate to patients. Although the easi- unit’s mission-essential tasks, the physician is better est time to learn these skills is early in one’s career, it able to interpret injury patterns and set reasonable is never too late to begin and it is always appropriate return-to-duty requirements and limitations. In ad- to review and refresh these skills on a regular basis. dition, learning these skills establishes a set of shared Vice Admiral Joel Boone is arguably among the best experiences that facilitate effective communication examples of a combat physician. This is his Medal of between physician and patient. Honor Citation from World War I: At its core, soldiering skills consist of being able to safely and effectively shoot, move, and communicate. For extraordinary heroism, conspicuous gallantry, Each of these basic tasks has a series of implied tasks. and intrepidity while serving with the 6th Regiment, For example, to shoot, one must first know how to U.S. Marines, in actual conflict with the enemy. With safely handle and sight-in (or “zero”) the weapon. absolute disregard for personal safety, ever conscious and mindful of the suffering fallen, Surg. Boone, To move, one must know how to establish his or leaving the shelter of a ravine, went forward onto her position and navigate. According to the tenets of the open field where there was no protection and de- the Geneva Conventions, medical personnel are not spite the extreme enemy fire of all calibers, through combatants and are entitled to certain protections a heavy mist of gas, applied dressings and first aid (so long as they are working exclusively in a medical to wounded marines. This occurred southeast of Vi- role and not participating in acts harmful to the en- erzy, near the cemetery, and on the road south from emy).1–3 However, the vast majority of armed conflicts that town. When the dressings and supplies had been the United States has engaged in since World War II exhausted, he went through a heavy barrage of large- include combatants that do not adhere to the Geneva caliber shells, both high explosive and gas, to replen- ish these supplies, returning quickly with a sidecar Conventions. Thus, the physician cannot assume the load, and administered them in saving the lives of the protections of Geneva Conventions status and must wounded. A second trip, under the same conditions be prepared to be treated as a combatant. and for the same purpose, was made by Surg. Boone As a rule, units are willing to facilitate teaching their later that day.4 assigned physician combat skills if he or she shows an interest. It is beneficial to the unit to have a physician In addition to earning the Medal of Honor, Boone who is independent and competent in a combat zone; a was awarded the Army’s Distinguished Service Cross, physician cannot execute the critical medical role if he multiple Silver Stars, and many other awards, making or she is lost or dead. Deployable medical units have him among the most decorated military physicians a cadre with the responsibility to teach basic combat in history.5 With one of the most remarkable and dis- skills to their medical providers. In other units, a phy- tinguished careers in the history of the US military, sician with initiative and persistence will find trained Vice Admiral Boone demonstrated preparedness and personnel and resources to help. Learning combat readiness that led to courage and success when it re- skills is experiential; reading it in a book, seeing it on ally counted. He is an excellent example for all military a video, or being told what to do will not suffice. The physicians. THE PROBLEM AND NEED FOR TRAINING With the exception of Special Operations units, no for these physicians to regularly train in combat skills service officially requires physicians to become profi- with their unit members is expected. In all other units, cient or familiar with any combat skills, and military pursuing training in these skills is the physician’s re- units often do not place any demands on the physician sponsibility; it is often not provided by the unit. outside of medical tasks beyond the minimum military As a result, physicians may receive only a half-day requirements. Special Operations units expect their of familiarization with a pistol, while the remainder physicians to have (from prior service) or to develop of readiness preparation involves updating medical/ the ability to handle themselves in rapidly changing dental/immunizations requirements; ensuring their situations, including combat. Thus, the opportunity security clearance and ISOPREP (isolated personnel 154 Tactical Field Skills for the Military Physician report, a secure individual profile on file in case a Advanced Trauma Life Support or Advanced Cardiac person must be rescued and their identity verified) is Life Support standards. However, medics will look up to date; and making sure various computer-based to the unit physician for medical training, validation, training is current. These kinds of activities, although and mentorship. The physician must have an in-depth important for deployment readiness, do not constitute understanding of TCCC principles and techniques tactical field skills preparation or adequately prepare to be able to communicate in a common language the physician for working in a combat environment. and utilize the same treatment algorithms when it is The unit may facilitate scheduling combat arms train- necessary to provide care under fire. Physicians need ing but not offer extra training such as combatives, land to train medics in TCCC-recommended medications navigation, or small team tactics. for pain control and wound prophylaxis; medics have Likewise, training as a physician does not include the know-how to administer medications but may preparation for combat field medicine. Experienced not fully understand how they work or when certain combat-proven medics often know more about saving medications may be better than another. It is important lives of wounded warfighters in the field than physi- to practice how to care for casualties out of an aid bag, cians. Medics are experts in Tactical Combat Casualty including in the dark. Practice improves performance Care (TCCC),6 and it behooves the military physician to not just individually, but also collectively between the learn and be able to execute these standards as well as tactical physician and medic. SHOOT Weapons Training provides first-hand experience with the occupational noise exposure warfighters face, which emphasizes the In a combat zone, the physician is usually assigned importance of advocating for the funding and enforce- a weapon, most often a pistol (M9) or possibly a rifle ment of appropriate hearing protection. In addition, (M4). Even under almost all theater-established rules shooting can be a significant source of occupational of engagement, medical personnel never lose the right lead exposure, especially for personnel who routinely to self-defense according to the Geneva Conventions. shoot in indoor ranges. The unit physician should Rules of engagement vary with the threat level and track shooting-associated occupational concerns such phase of combat operations. For example, in the initial as proper ventilation in firing ranges, hand-washing assault phase of a combat operation, a soldier may immediately after firing range operations, and blood legally shoot any enemy holding a weapon, whereas lead level monitoring in populations that routinely fire in the stabilization phase of combat operations, the assigned weapons. In addition, going to the range and soldier may have to wait until that same enemy makes firing weapons once or twice a year provides physi- a threatening gesture before shots can be fired. By the cians an opportunity to get to know their patients in Geneva Conventions, however, as medical personnel, a nonclinical setting. physicians can shoot only if threatened and there is a The ideal time to learn how to safely handle and need to protect their own life or the life of patients.7 employ firearms is before deployment; during deploy- In such cases, deadly force may be used. It is vitally ment is too late to become comfortable with a weapon. important to understand such rules of engagement Weapons may be assigned because of an increased within the confines of the Geneva Conventions, and threat level, and there is no time to become proficient medical personnel must be ready to utilize deadly with a weapon once an assault starts.

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